ELDERCARE QUESTIONNAIRE
Below are some questions I ask to evaluate what a persons needs or concerns are as they relate to themselves or a loved one. Take your time and think through your needs and answer these questions. This helps me to be able to assess individual concerns, risks and needs. I want to give you the resources and information that apply to your specific situation.My advice or suggestions are Strictly out of Knowledge, Experience and Resources. I do not advise on Legal or Medical issues please seek an Attorney or Physician.
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| INSTRUCTIONS: WHERE THERE IS A SMALL BOX ( CLICK ) TO ANSWER. BY CLICKING YOU ARE INDICATING THAT AS YOUR ANSWER. WHERE THERE IS AN EMPTY BOX - ( TYPE ) INFORMATION
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Your name: [optional]
E-mail address: Required**
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Who are you seeking information for?
Self
Family Member
Other
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What are your main concerns about?
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Health Matters
Is there a chronic condition like diabetes or heart disease?
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Medication
If so, please list if known
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Memory
Please describe your concerns
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Safety
Please describe your concerns
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Nutrition
Please describe your concerns
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Hygiene
Please describe your concerns
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Mobility
Please select the mobility of the patient:
Bed-bound
Walker
Wheelchair
Walks with cane
Walks alone- no assistance
Please describe your concerns
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Current housing information:
Lives alone.
Lives with family.
Single dwelling
Apartment
Assisted Living
Long Term Care Facility
Other, please explain below
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Death and Dying
Are there any concerns or questions regarding:
Wills
Advance Directives
Power of Attorney
Health Care Proxy
Hospice
Other concerns
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Planning for potential needs can be anxiety-producing, but keep in mind that by thinking through these issues now, you will feel more confident and prepared should a crisis situation present itself.
Comments you would like to include: (optional)
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